(Customize this document for your specific organizational needs.)
Example Fetal Monitoring Policy & Procedure
Policy No:
Page: 1 of 4
Effective Date:
Responsible Dept./Committee:
TITLE:
Policy Origin Date:
Dated:
FETAL MONITORING
PURPOSE:
To provide standardized interpretation and communication regarding fetal heart rate
(FHR) and uterine contraction (UC) data based on criteria set forth by the National
Institute of Child Health and Human Development (NICHD) during fetal monitoring.
POLICY:
At all hospital encounters, pregnant patients will be assessed for spontaneous labor and
fetal heart rate by appropriate methods based on gestational age and risk-status.
1. All pregnant patients are assessed upon ER triage, OB triage, and/or admission for
spontaneous labor and fetal heart rate data. Interpretation and communication of
uterine contraction and fetal heart rate data is based on NICHD criteria. This criteria is
endorsed by all of the following:
 American College of Obstetrics and Gynecology (ACOG)
 Society of Maternal Fetal Medicine (SMFM)
 Association of Women’s Health, Obstetric, and Neonatal Nurses
(AWHONN)
 American College of Nurse Midwives (ACNM)
2. Interpretation and communication of FHR and UC data requires advanced assessment
and clinical judgment skills in electronic fetal monitoring (EFM) regardless of the
setting in which it is used. Therefore, each aspect of EFM should be performed by
licensed, experienced health care professionals consistent with their state or provincial
scope of practice. Physicians, registered nurses, advanced practice nurses (Nurse
practitioner or Clinical Nurse Specialist), certified nurse midwives, physician
assistants, and residents are nationally recognized practitioners who may be skilled in
EFM. Proficiency and competency is validated at a frequency relative to the patient
population served at the facility. On-going multidisciplinary continuing education is
necessary to maintain skill and competency in EFM.
3. AWHONN staffing guidelines are required for the duration of fetal monitoring. Please
refer to the AWHONN (2010) reference in this document for specific requirements as
criteria varies according to risk-status, pain relief, and stage of labor.
(Customize this document for your specific organizational needs.)
Example Fetal Monitoring Policy & Procedure
Policy No:
Page: 2 of 4
Effective Date:
Responsible Dept./Committee:
Policy Origin Date:
Dated:
PROCEDURE:
1. FHR and UC data may be interpreted and communicated based on the following:
a. METHODS: Determine the appropriate method of interpretation based on
gestational age, risk-status, and physician order. It is important that a woman’s
preference be taken into account whenever possible when deciding on FHM
techniques:
1) Auscultation: intermittent assessment of the FHR with either aa. Doppler Ultrasound
b. Fetoscope
2) Manual Palpation: intermittent abdominal assessment of UC data with
manual interpretation of the uterine fundus.
3) Electronic Fetal Monitoring (EFM): intermittent or continuous assessment
of the FHR and UC data with an electronic medical device. Both FHR and
UC data may be interpreted with external or internal devices:
a. External:
i. Ultrasound transducer-uses Doppler technology to assess
FHR data
ii. Tocodynamometer- uses pressure technology to estimate
UC data
b. Internal:
i. Fetal Scalp Electrode (FSE) or Fetal ECG (FECG)- applied
to fetal presenting part for direct assessment of FHR
ii. Intrauterine pressure catheter (IUPC)- permits direct
assessment of UC data from within the uterine
compartment. Montevideo units (MVUs) may be calculated
with this device.
b. ASSESSMENT PARAMETERS: Assessment is based on the method used.
Frequency of assessments are based on risk-status and are outlined in the
AWHONN Position Statement (2008).
1) Auscultation:
o FHR Baseline rate
o Presence or absence of audible decelerations
2) Manual Palpation:
(Customize this document for your specific organizational needs.)
Example Fetal Monitoring Policy & Procedure
Policy No:
Page: 3 of 4
Effective Date:
Responsible Dept./Committee:
Policy Origin Date:
Dated:
o Frequency, duration, intensity, & resting tone
3) EFM
o FHR: baseline rate, variability, periodic or episodic patterns
(accelerations or decelerations)
o UC: Frequency, duration, intensity, & resting tone
c. FHR/UC INTERPRETATION & COMMUNICATION: Both FHR and UC data are
interpreted and communicated based on criteria set forth by NICHD terms and
guidelines outlined in the EFM Dictionary Tool (2014) (located also in this section
of the toolkit).
d. FHR/UC INTERVENTIONMANAGEMENT: Management of FHR and UC
patterns is based on the ACOG 3 Tier FHR Category (ACOG, 2009) System, and
ACOG intrapartum management algorithms (ACOG, 2010). The EFM Dictionary
Tool also contains evidence-base, peer-reviewed guidelines and recommendations
for specific FHR and UA patterns that may be observed during EFM.
e. EFM COMMUNICATION: All forms of communication, both written and verbal,
will include NICHD terminology. Perinatal practitioners will document all
communication within the electronic medical record to include: name, credentials,
time of notification, response time, clinical data, actions/interventions, and patient
response. Forms of communication may include:
o
o
o
o
o
Phone calls
Hospital electronic medical record (EMR)
EFM EMR
Change of Shift Reports: RN-RN
Hand-off Reports: MD-MD, MD-CNM, CNM-CNM
o Hospital documentation of any nature that may include EFM data
Documentation should contain streamlined, factual and objective information and
should include, but may not be limited to:






a systematic admission triage and/or assessment of the woman and fetus;
periodic assessments of the woman and fetus;
interventions provided and evaluation of responses,
communication with the patient and their families or primary support persons;
communication with providers
communication within the chain of authority
f. CHAIN of AUTHORITY: A formal line of communication among perinatal
staff members to discuss concerns regarding patient care. Both the hospital and
medical staff will use open and clear communication skills that optimize a
(Customize this document for your specific organizational needs.)
Example Fetal Monitoring Policy & Procedure
Policy No:
Page: 4 of 4
Effective Date:
Responsible Dept./Committee:
Policy Origin Date:
Dated:
mutually acceptable resolution with a focus on patient safety. The focus of
resolution should be between the two primary care providers. If this is not
possible, additional individuals may become involved at the request of any
involved party:
i. A ddi t i on al st af f R N
ii. C h arg e Nur se
iii. N ur se M an age r
iv.
v.
vi.
vii.
viii.
ix.
P hy si ci a n part ner/ col l e ag ue
Director of OB/Women’s Health
Medical Director
OB Director
Chief of Staff
CEO/Administrator on-call
g. PATIENT EDUCATION: Patient education regarding fetal monitoring should
include: indications, contraindications (if any), and findings. Questions are
addressed and answered periodically during the procedure as indicated by
patient request.
REFERENCES:
1. American College of Obstetricians and Gynecologists (ACOG). (2010/2013). Management of
2.
3.
4.
5.
6.
Intrapartum Fetal Heart Rate Tracings Surveillance (Practice Bulletin #116). Washington,
DC: Author.
ACOG. (2009/Reaffirmed 2013). Intrapartum Fetal Heart Rate Monitoring: Nomenclature,
Interpretation, and General Management Principles (Practice Bulletin # 106). Washington,
DC: ACOG.
Association of Women’s Health, Obstetric, & Neonatal Nurses (AWHONN). Guidelines for
professional registered nurse staffing for perinatal units. 2010. Washington DC: Author.
AWHONN. Fetal heart monitoring (Position Statement).2008. Washngton DC: Author.
LAMMICO/Medical Interactive. EFM Dictionary Tool.2014.New Orleans, LA: Author.
Macones, G. A., Hankins, G. D., Spong, C. Y., Hauth, J., & Moore, T. The 2008 National
Institute of Child Health and Human Development Workshop Report on Electronic Fetal
Monitoring: Update on definitions, interpretation, and research guidelines. Obstet &
Gynecol, 2008 ; 112(3):pp. 661-666.